Disabilty_Pohl .E.R-•��4 APPLICATION FOR BLIND OR DISABLED PERSON'S COUNTY TOWNSHIP YEAR
DEDUCTION FROM ASSESSED VALUATION
• ateForm (R13 -20) ro�n
� :.. St 43710 /1 t! ,
e16 Prescribed by the Department of Local Government Finance t Ili)r1
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
���""",,,"` File Mark
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Date Form must be completed and signed by December 31 and filed or postmarked by the following January 5 of the calendar year in which the
property taxes are first due and payable
430
See reverse side for additional instructions and qualifications 11 I ` 1
Name of applicant(owner or contract buyer)
t'C:iC'1,Ua Poh 1
Is applicant the sole legal or equitable owner? If No,what is his'her exact share of interest? If owned with someone other than spouse.
�//'' indicate with whom:
Lv�"Yes ❑ No
If name on record is different than that of applicant,indicate below
Name of contract seller
Pr
Address of contract seller(number and street.city,state.and ZIP code) Is the5Aperty in question
Real Property ❑ Annually Assessed Mobile Home(IC 6-1.1-7)
is applicant blind as defined in IC 12-7-2-21(1)7 Is applicant disabled and unable to engage in any substantial gainful activity
/� as defined in IC 6-1 1-12-11(d)?
❑ Yes B4 es d
Is the property used and occupied primarily for his/her residence") Does the applicant's taxable gross income for the preceding calendar year
exceed S17,0009
Yes ❑ No ❑ Yes O
Taxing district Key number/Legal description Record number(contract) Page number(contract)
kor - -aoa-000 lash -C L
I/We certify under penalty of perjury that the above and foregoing information is true and correct
Signature of applicant I Address of applicant (number and street.city state,and ZIP code)
./(!k?; /•- Poo ; -I v3 - . �
Signature of authorized representative Address of authorized representative (number and ltreef,city state.and ZIP code) Q� )
RECEIPT FOR APPLICATION FOR DEDUCTION FOR BLIND/DISABLED PERSONS
Name off applicant Date filed(month. day year)
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•Name of contract seller FILED
Taxing district MAY 01 2024
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Key number/legal description
GIBSON COUNTY AUDITOR
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Signature of County Auditor Date signed(month,day,year)
• -
Illluuilluil.111111IIuiinll,i„I„Ili,Ii,I„III11111IIIi„iiiii
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0000144 00016936 2 SP 0.8R0 02ORM3MCS4P1 1'121 P 0
0
CHRIS POHL
pkirgi 188 W 975 S
IIAUBSTADT, IN 47639-7805
You are entitled to monthly disability benefits beginning May 2023.
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